Review Article 어지럼증의재활치료 김종문 김형섭 국민건강보험일산병원재활의학과 Rehabilitation Approach for Dizziness Jong Moon Kim, M.D and Hyoung Seop Kim, M.D. Department of Physical Medicine and Rehabilitation, National Health Insurance Corporation Ilsan Hospital, 100, Baekseok-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, Korea Abstract Dizziness is a common symptom in elderly patients, which can lead to balance problems leading to fall injuries. Increase in dizziness in elderlies can be attributed to deterioration of the sensory orgrans, sensory intergration organs and ageing process of motor function, or other related diseases. Dizziness can be categorized to peripheral/central vertigo, disequilibrium, presyncope or light-headedness, all of which can be differentiated by careful history taking. Rehabilitation therapy can be applied to any disease that causes dizziness, but it is primarily indicated for patients with recurring dizziness. The mechanism for improvement and the rehabilitation therapy of dizziness relies on the plasticity of the brain, which undergoes adaptation, habituation and substitution. Whilst vestibular rehabilitation and balance exercise methods are effective and causes little side effects for patients with dizziness, the Epley maneuver or Brandt-Daroff exercise are more effective in patients with benign paroxysmal positional vertigo. In conclusion, balance exercise for dizziness should aim to relieve acute dizziness symptoms, prevent fall injuries, and increase the patients independence in daily activities. Key Words Dizziness, Vertigo, Postural balance, Exercise 접수일 : 2014년 7월 25일게재승인일 : 2014년 8월 8일교신저자 : 김형섭주소 : 경기도고양시일산동구백석로 100 국민건강보험일산병원재활의학과 Tel : 82 31 900 0137 Fax : 82 31 900 3393 e-mail : rehappydoc@gmail.com 서론 어지럼증 ( 현기증, dizziness) 은자아와주변환경에대한왜곡된관계에대한감각을표현하는포괄적인말로정의될수있다. 1 어지럼증은결국균형유지기전의손상과관련이있으며, 따라서균형을유지하는기전의이상에따라어지럼증을느끼는환자들은미묘한차이를 어지럽다. 빙빙돈다. 쓰러질것같다. 균형이잡기어렵다. 등등으로표현하기도한다. 어지럼증과균형장애 (imbalance) 는고유수용체감각, 시각, 청각, 근력이상, 퇴행성신경장애에의해서발생하게된다. 2 노인에게서는어지럼증은흔한증상으로 13-38% 정도가경험을하게된다고하며, 남성보다는여성에서흔하다. 3 연령이증가할수록균형유지기전의손상이발생할확률이올라가며 (Fig. 1), 결국다양한원인으로인한어지럼증은노인의낙상위험도를올리게된다. 2 낙상은노인에있어서병원입원과사고사의주요원인이며, 공중보건학적으로도큰문제가된다. 19
Visual Presbyopia Cataract Vestibular Hair cell loss Neuronal loss Somatosensory Neuropathy CNS Neuronal loss Musculoskeletal system Muscle atrophy Comorbidity-Medication Anti-hypertensive Medication Ototoxicity medication CNS medication Urologic medication Fig. 1. Age-dependent changes in postural stability Sensory input Intkration of input Motor input Balance Vestibular Equilibrium Spatial awareness Rotation Linear movement The cerebellum coordinates and regulates posture, movement, and balance. Vestibulo-ocular reflex Visual Sight The cerebral cortex contributes higher level thinking and memory. Motor impulses to control eye movements Balance Priprioceptive touch The brainstem integrates and sorts sensory information. Motor impulses to make postural adjustments Fig. 2. Components of balance. 또한낙상을경험한사람은신체활동에대한두려움이발생하기때문에, 활동의저하로인한관절구축과근육위약으로발생하여이것이또한어지럼증및균형장애를일으키는악순환이된다. 전정기관재활 (vestibular rehabilitation) 은전정기관의이상으로인한재활운동치료로국한된것으로알려져있지만 1,4 결국균형이문제가생기기때문에균형에장애를일으키는파킨슨병, 다발성경화증, 뇌졸중및두부손상등어지럼증과 이에따른균형장애로발생한어떤질환도치료의적응증이된다. 5,6 따라서어지럼증에대한균형운동의목적은급성증상의해소와낙상예방, 일상생활동작수행의독립성증가에맞추어야할것이다. 20
Table 1. Differential Diagnosis of Dizziness Vertigo Presyncope Disequilibrium Lightheadedness Sensation Rotational : Spinning or whirling Lightheaded, faint feeling Unsteadiness; loss of balance on walking Vague; may be floating sensation Temporal characteristics May be episodic or continuous Typically episodes last seconds to hours Usually present, although it may fluctuate in intensity Usually present all or most of the time for days or weeks, sometimes years Stimulation tests Dix-Hallpike test Orthostatic blood pressure measurement Romberg test, Tandem gait Hyperventilation Differential diagnosis Peripheral Vestibular disease Central Vestibular disease - Arrhythmias - Vasovagal reflex - Orthostatic hypotension - Anemia - Aortic stenosis - Low cardiac output states - Carotid sinus hypersensitivity - Hypoglycemia - Hypoxemia - Multiple sensory deficits - Altered visual input - Primary disequilibrium of aging - Parkinsonism - Cerebellar disease - Frontal lobe apraxia - Drug use - Anxiety - Depression - Hyperventilation - Panic disorder 본론 1) 균형 균형 (Balance) 은신체의체중중심 (center of gravity) 을지지 (support) 의기초위에두는능력을말한다. 7 균형은크게시각, 고유수용체, 전정기관에서들어온감각자극 (sensory input) 과감각기관에서수용된자극을통합하는소뇌 (cerebellum), 대뇌피질 (cerebral cortex), 뇌간 (brain stem) 이있으며, 통합된자극은안구운동이나, 양측하지의운동기관으로나가게된다. 따라서감각기에이상이있거나, 뇌간이나소뇌경색이나출혈, 뇌졸중으로인한하직근력위약이나, 구축, 이상감각이있을경우모두불균형을초래하게된다 (Fig. 2). 7 (1) 어지럼증의분류 3,5,6 어지럼증을경험하는환자들은지속적으로일관된반응을보이지않으며또한오심, 구토, 두통등의동반된증상으로 인하여진단에쉽게접근하기가어렵다. 때문에처음의환자들의표현을바탕으로, 다양한원인을유추하는것이중요하다. 어지럼증은현훈 (vertigo), 불균형 (disequilibrium), 전실신 (presyncope), 어찔감 (lightheadedness) 으로나누어볼수있다 (Table 1). 가 ) 현훈 (vertigo) 말초성어지럼증으로 45-54% 정도의환자들이해당하며토하거나오심이나타나는뱃멀미와같은증상과함께빙빙도는느낌을호소한다. 말초성어지럼증은고령에서특히증가하게되며, 이는양성위치성현훈 (BPPV : benign paroxysmal positional vertigo), 메니에르병 (meniere's disease) 의유병률이나이가들어감에따라증가하는것과관련이있다. 말초성어지럼증은내이의출혈이나혈관의폐쇄와같은혈관성질환, 바이러스나세균, 결핵등의염증성질환, 청신경종양과같은종양성질환이있으며, 외상으로인한두개골골절, 파열등도원인이될수있다. 또한멀미와같은외부자극에의한것도일종의말초전정계어지럼증의하나로볼수있 21
으며, 이밖에발병기전이밝혀지지않은것도많다. 나 ) 불균형 (disequilibrium) 중추성어지럼증으로 16% 이상의환자들이해당하며, 균형이떨어지거나흔들거리는느낌을받는다고하고, 어지럽다는느낌보다는중심을잡기어려워한다. 청장년기에잘발생하는기저동맥편두통에의한어지럼증은고령에서는드물게발생하며, 주로간뇌나소뇌의혈관이상에서오는의한뇌졸중에의한 2차손상으로나타나게된다. 이밖에특징적으로격심한회전성어지럼증 (quick spins) 을호소하는간질발작에의한경우도있다. 다 ) 전실신 (presyncope) 내과적문제의의한어지럼증으로 14% 이상의환자들이해당하며, 정신이몽롱해지면서힘이빠지고시야가캄캄해지는느낌이든다고한다. 원인은매우다양하지만주로심혈관문제 ( 저혈압, 심장이상 ), 감염, 저혈당, 약물에의한것이많다. 이중약물은노인환자들에있어서는많은종류의약물을동시에복용하는경우가많기때문에더욱흔하며, 실제로저혈당과함께기립성저혈압의가장흔한원인이다. 라 ) 어찔감 (lightheadedness) 심인성어지럼증으로대략 10% 의환자들이해당한다. 대부분의환자는모호한증상을호소하며, 주위환경과분리되는듯한기분을호소한다. 불안, 공황장애, 광장공포증에의해나타날수있으며, 종종기질적인원인에의한어지럼증과동반되는경우가많아서진단에주의를요한다. 마 ) 원인이분명하지않은어지럼증모든연령에서어지럼증을호소하는환자의약 1/3은정확한진단이되지않는다. (2) 어지럼증의경과와균형운동치료전정재활및균형운동의적응증은위에서언급한바와같이균형의장애를일으킬수있는모든질환이대상이되며증상이반복되는환자에게일차적적응증이된다. 대부부의말초성어지럼증은시간이지나면좋아지며이는중추신경계의가소성 (plasticity) 에의한것이다. 1,8 이러한중추신경계의가소성은적응 (adaptation), 습관화 (habituation), 대치 (substitution) 의기전으로일어난다. 6,9 적응은전정기관의감각입력의변화를중추신경이적응하는것을말하며, 습관화는어지럼증을일으키는자극을반복함으로써어지럼증의강도를감소시키는전략을말하며, 대치는전정기관의이상을시각이나고유수용체감각을이용하여균형을유지하는것을말한다. 전정재활및균형운동은또한뇌의가소성의기전을 Table 2. Adaptation and Habituation Exercise Training for Motion-Provoked Symptoms Bed rolling Supine to right lateral Supine to left lateral Supine to sitting Supine to sit straight Sit to left Hallpike Left Hallpike to sit Sit to right Hallpike Right Hallpike to sit Sitting with head movement Side to side Up and down Circular fashion clockwise Circular fashion counterclockwise Sit to bend forward Sit touch nose to right knee Sit touch nose to lift knee Sit to stand Stand sudden turn to right Stand sudden turn to lift Stand bend forward and up 이용한다. 전정안구반사운동 (vestibule-ocular reflex exercise) 은적 응기전을이용한것이다. 전정안구반사운동 1 은주시할목표 를손에쥐고, 머리회전과반대로움직이면서도환자는목표 를지속적으로주목하는운동법이다. 또한목표를위아래로 움직일수있으며, 이때도목표를따라안구가따라가게한다. 전정안구반사운동 2 는환자전면에고정된목표를두고, 고개 를돌리더라도안구는지속적으로목표를보게하는방법이 다. 습관화는 Table 2 에서보여주는것과같이, 누워있다가앉 거나혹은앉아있는상태에서고개를돌리거나, 앉아있다서 있는등다양한방법으로위치를변경시켜오히려어지럼증을 유발시킨다. 그러나반복적으로운동하면서, 어지럼증의강도 와기간이서서히감소하는것을기대하게된다. 대치를이용 한것은시각적교정및고유수용체감각훈련이있으며, 지 팡이혹은안전바를잡아균형을유지하거나, 폭이넓은신발 을이용하는등, 다양한방법을통하여균형을잡는훈련이다 (Table 3). 또한균형을잃게될때적응하는운동법이있다. 크게교 정반사운동 (corrective response exercise) 과보호반사운 동 (protective response exercise) 이있다. 1 교정반사운동은 22
Table 3. Substitution Exercises Motor Challenges Visual Challenges Visual +Vestibular Challenges (Head movement, HM) Visual + Vestibular + Somatosensory Challenges (Standing On Foam, SOF) Eyes Open (EO) (a) Eyes Closed (EC) (b) HM/EO (c) HM/EC (d) SOF/EO (e) SOF/EC (f) SOF/ HM/EO (g) SOF/ HM/EH (h) Standing Feet Together In Tandem On one leg Walking 줄타기를하는곡예사의운동법을생각하면쉽다. 즉환자로하여금균형을잃게될경우, 발목이나고관절의축을중심으로무게중심을두도록앞뒤로움직이거나팔을이용하여균형을잡는법이라고보면된다. 또한보호반사는넘어질경우다리나팔을뻗어머리나몸통을보호하는방법이된다. 이는유도나합기도와같은무술에서구르기나떨어질때우리몸을보호하는낙법의형태로생각하면이해하기가쉽다 (Table 4). 말초전정기관이상으로인한재활운동치료에대한대규모메타분석의결과는균형운동치료가어지럼증의횟수를줄이고어지럼증으로인한일상생활동작수행의장애가호전되며, 운동으로인한부작용이관찰되지않는다고보고하였다. 10 그러나양성위치성현훈일경우는균형운동치료보다는 Epley 교정법이나자가운동인 Bradt-daroff 운동법이더욱 효과적이라고하였다. 10 결론 균형을유지하기위해서는감각자극, 자극통합, 운동기관의상호유기적인작용으로이루어지며노화가진행되면, 감각기관및통합기관, 근력위약, 동반된질환, 약물복용등으로균형의문제가발생하게된다. 노인에게서어지럼증은낙상으로이어질수있기때문에정확한진단이필요하며여기에맞추어일차적인치료적접근이필요하다. 왜냐하면일부말초성원인에의한어지럼증은재활운동치료보다는일차적 23
Table 4. Exercise to Improve Postural Response Strategies Corrective response exercise 1. Ankle response Stand on solid platform longer than size of feet and rock back and forth about ankle without bending hip joint for 30 seconds with eyes open and closed. 1. 2. Hip response Stand on compressible surface or surface which is shorter than the size of feet (e.g., round pipe) and rock back and forth bending at hip for 30 seconds 2. 3. Stiffening response Contract all the agonist and antagonist muscles of the ankle, knee, hip joint, lumbosacral spine and neck muscles (vibration surface). 3. 4. Counterbalance response Counterbalancing movement of the arm to maintain COG over the BOS. 4. Protective response exercise 5. Stepping response. 6. Grabbing of external support response. 7. Rescue response with support by outstreched arm to minimize impact of fall and break the fall. 5. 6. 7. 24
인원인교정과교정법이더욱효과적이기때문이다. 따라서전정기관재활운동및균형운동은큰부작용이없으므로, 말초어지럼증뿐만아니라중추신경등여러가지질환으로인한어지럼증에도적응증이되므로노인들의활동성유지및안전사고예방을위해전정기관재활운동및균형운동이적극적으로권장되어야하겠다. REFERENCES 1. Parikh SS, Bid CV. Vestibuluar rehabilitation. In: Delisa editor. Physical medicine and Rehabilitation, 4th ed, Philadelphia: Lippincott Williams & Wilkins;2005 2. Barin K, Dodson EE. Dizziness in the elderly. Otolaryngologic Clinics of North America. 2011;44:437-454 3. Alghadir AH, Iqbal Za Fau - Whitney SL, Whitney SL. An update on vestibular physical therapy. 20130121 DCOM- 20131219 (1728-7731 (Electronic)). 4. Yardley L, Beech S, Zander L, Evans T, Weinman J. A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care. Br J Gen Pract. 1998;48:1136-1140 5. Alrwaily M, Whitney SL. Vestibular rehabilitation of older adults with dizziness. 20110408 DCOM- 20110811 (1557-8259 (Electronic)). 6. Iwasaki S, Yamasoba T. Dizziness and imbalance in the elderly: Age-related decline in the vestibular system. Aging and Disease. 2015;6:38-47 7. The Human Balance System A Complex Coordination of Central and Peripheral Systems. vestibular.org/ sites/default/files/page_files/documents/human%20 Balance%20System.pdf. 8. Igarashi M. Vestibular compensation. An overview. Acta Oto-laryngologica. Supplementum 1984;406:78-82 9. http://vestibular.org/sites/default/files/page_files/ Vestibular%20Rehabilitation_0.pdf 10. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. The Cochrane database of systematic reviews. 2015;1:CD005397. 25